Fillable COVERAGE IN MARYLAND NOTICE CONCERNING THE WAIVER OF (Risk Placement Services, Inc.)

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COVERAGE IN MARYLAND NOTICE CONCERNING THE WAIVER OF (Risk Placement Services, Inc.)

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M-5411 (08/2009)
M-5411 (08/2009) Page 1 of 2
NOTICE CONCERNING THE WAIVER OF PERSONAL INJURY PROTECTION (PIP)
COVERAGE IN MARYLAND
You have the choice of purchasing certain Personal Injury Protection (PIP) coverages. Before deciding whether to
purchase or waive this coverage, please read the following carefully.
Full PIP coverage provides the following protection, without regard to fault:
1. It covers you and members of your family residing with you who are injured in any motor vehicle accident;
anyone injured while in your vehicle; and pedestrians injured by your vehicle.
2. The minimum coverage is $2,500 and may be used to cover:
a. All reasonable and necessary medical expenses incurred within 3 years of injury; and
b. 85 percent of actually incurred lost wages; or
c. If the injured person is not employed at the time of injury, any reasonable and necessary
expenses to provide for essential services which that person would have provided for the care
and maintenance of his or her family or household.
If you do not sign the waiver, you will automatically receive the full PIP protection described above. Your PIP
premium will be $
. You may only waive PIP coverage for:
1. The named insured (you);
2. All listed drivers on the policy; and
3. Members of your family who are 16 years of age or older and reside with you in your household.
The waiver prevents the named insured (you) from collecting PIP benefits under any motor vehicle liability
insurance policy issued in the State of Maryland or another form of security authorized to be used in place of a
motor vehicle liability insurance policy. The waiver prevents individuals described in category 2 or 3 above from
collecting PIP benefits under your policy. In addition, if these individuals are involved in a motor vehicle accident,
the waiver prevents these individuals from collecting PIP benefits under any other policy of motor vehicle liability
insurance issued in the State of Maryland or another form of security authorized to be used in place of a motor
vehicle liability insurance policy unless the individual:
- Is the first named insured under the other policy;
- Has not waived PIP benefits under the other policy; and
- Is not a named insured under any policy of motor vehicle liability insurance where a waiver of PIP benefits
is in effect.
The waiver does not impair the rights of other individuals such as pedestrians or minor children from collecting
PIP under your policy.
If you decide to sign the waiver, your PIP premium will be
percent of the full PIP coverage. The total
premium will be $
.
If you decide not to sign the waiver, your insurance company may not refuse to write your insurance coverage.
M-5411 (08/2009)
M-5411 (08/2009) Page 2 of 2
WAIVER OF PERSONAL INJURY PROTECTION (PIP) COVERAGE IN MARYLAND
I hereby confirm that I have fully read and understood the attached notice, required by Section 19-506 of
the Insurance Article, and I understand and agree that
, in
reliance upon my signature as the first named insured/applicant, will NOT provide the Personal Injury
Protection (PIP) coverage required by Section 19-505 and described in the attached notice provided to me
with this waiver. This coverage is waived for any injury which may be sustained by:
1. Anyone listed as a named insured on the policy;
2. All drivers listed on the policy; and
3. All members of the named insured's family living in the insured's household who are 16 years
of age or older.
I further understand and agree that the waiver of Personal Injury Protection (PIP) benefits under the policy
being applied for waives coverage for PIP benefits for anyone described above under any other policy
issued in the State of Maryland or another form of security authorized to be used in place of a motor
vehicle liability insurance policy, unless the individual:
- Is the first named insured under the other policy; and
- Has not waived PIP benefits under the other policy; and
- Is not a named insured under any policy of motor vehicle liability insurance where a waiver of PIP
benefits is in effect.
I, the first named insured/applicant, have fully read and understood the above noted information and
hereby affirmatively waive the benefits required by Section 19-505 of the Insurance Article (PIP). I
understand and agree that this waiver of coverage shall be applicable to the policy or binder of insurance
described below, on all future renewals of the policy, and on all replacement policies unless I notify the
company in writing to the contrary with the effective date of such change being no earlier than the receipt
date by the company of my written notification.
First Named Insured/Applicant
# #
Signature of First Named Insured/Applicant Date
Policy #
Insurer
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COVERAGE IN MARYLAND NOTICE CONCERNING THE WAIVER OF (Risk Placement Services, Inc.)

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Completed 23 November 2020

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